Provider Demographics
NPI:1043262553
Name:BURCH, JOHN GORDON (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GORDON
Last Name:BURCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4461 STARKEY RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-0620
Mailing Address - Country:US
Mailing Address - Phone:540-342-0211
Mailing Address - Fax:540-344-5543
Practice Address - Street 1:4431 STARKEY RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-0612
Practice Address - Country:US
Practice Address - Phone:540-342-0211
Practice Address - Fax:540-344-5543
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010307652084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006180892Medicaid
VA131947858Medicare ID - Type Unspecified
VAB07692Medicare UPIN